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The Thinking Practitioner Podcast:
Episode 42: Scars and Scar Tissue (with Cathy Ryan)

Broadcast date: 06/30/2021
©Copyright The Thinking Practitioner Podcast, Til Luchau & Whitney Lowe

Til Luchau:

Til Luchau here. When I was looking for a publisher for a book I wanted to write, I was fortunate to have ended up with two offers, one from a large international media conglomerate, and the other from Handspring, a small publisher in Scotland run by four great people who love great books, and who love our field. 

To this day, I'm glad I chose to go with Handspring because not only did they help me make the books I wanted to share with you, The Advanced Myofascial Techniques Series, and they published a cool book co-authored by our guest today, so more on that coming up. But their catalog has emerged as one of the leading collections of professional level books written especially for body workers, movement teachers and all professionals who use movement or touch to help patients achieve wellness. 

Whitney Lowe:

Yes, and I'm Whitney Lowe, and Handspring's Moved to Learn! Webinars are free 45 minute broadcast, featuring their authors, including one with you Til. So head on over to their website at Handspring Publishing.com to check those out. And be sure to use the code TTP at checkout for a discount. So thank again Handspring. So Til we have a marvelous Handspring author, guest with us today. If I'm correct, is that right? 

Til Luchau:

Yeah, that's right. Cathy Ryan, you're here with us. Great to have you.

Cathy Ryan:

Thank you so much. It's a pleasure to be here.

Til Luchau:

Yeah. Do you like my scarves? 

Cathy Ryan:

I love your scarves. 

Til Luchau:

I got dressed up because we're going to talk about scarves, right?

Whitney Lowe:

Oh, yes. Scarves tissue today, I think.

Cathy Ryan:

Scarves tissue.

Til Luchau:

Scarf? 

Cathy Ryan:

Yes. 

Til Luchau:

Yeah, actually, it was about scars. Yeah. Scars and scar tissue. 

Whitney Lowe:

Okay. 

Til Luchau:

Yeah, the name your book is Traumatic Scar Tissue Management, Massage therapy principles, practice and protocols. And then you also wrote a cool article for Massage & Bodywork Magazine called Not Breakable, But Changeable. And you do some other cool stuff, like you do the Interdisciplinary Podcast with Cal Cates, you have some courses on the Healwell platform. I know, and probably a lot of other places. What else should people know about you? Actually no, I'm going to tell one more thing about you. 

I met you, like we were just reminiscing on a riverboat at the Berlin Fascia Congress in 2018, where we were seated next to each other for the dinner cruise on the river that we can't remember the name of. But I was picking your brain about inflammation, in particular, because that was, and still is my fascination, and was getting ready to launch a new course where I was actually trying to say something useful about inflammation to hands on therapists. And your input helped a lot. 

In fact, you turned me on to your book, and it's not on my list to talk to you about forever, because your book is awesome and I am really inspired by it and I learned a lot from it. And so it's just a pleasure to have you here talking to us. 

Cathy Ryan:

Hey, thanks so much. What should people know about me? I am one of those individuals, probably much like yourselves that is obsessed with fascia, which is kind of- 

Til Luchau:

Obsessed with fascia. 

Cathy Ryan:

Obsessed with fascia, which is what led me towards the scar tissue realm of things. I've worked with scar tissue over my 30 plus year career as a registered massage therapist. But it wasn't necessarily my practice focus, let's say. But because of my keen interest in fascia, I was interested in fibrosis, and then that connection with scars. As you mentioned, the fabulous people at Handspring, are responsible for, Mary Law in particular for getting Nancy and I to team up to do this book. I met Mary a number of years ago at an international massage therapy research conference. And she approached me, she was-

Til Luchau:

Mary Law is one of the editors at Handspring. And then you mentioned Nancy, that's Nancy Keen Smith your co-author. 

Cathy Ryan:

Yeah, Nancy Keen Smith. And Mary was aware that I had done some writing. I've been writing in the massage therapy profession for a number of years, mostly magazine type of stuff, curriculum. And Mary approached me and said, "Look, we just started this in publishing company, and I understand that you do some writing. I'm looking for somebody to do a book on scars. Does that interest you?" And I said, "Well, fibrosis certainly interest me." And I said, "But probably it'd be good to pairing up with somebody else who's more specific to scars." 

Nancy was presenting her burn scar work at that conference and Mary went to Nancy and said, "Hey, would you be interested in doing a book on scar tissue management. I've been wanting this topic covered by Handspring", and Nancy said, "Well I'm not a writer per se. So if you can find somebody to write with," and Mary said, "Aha, I have somebody in mind." And that's how we got together to do the book, because Nancy had been teaching scar tissue workshops for many, many years. 

Til Luchau:

All right, so you were the fibrosis and writing talent and you mixed sort of into that mix. I mean, what did you want to communicate in the book in a nutshell, because we'll get into some of the details as we go. But what was it, you were actually trying to communicate from your point of view?

Cathy Ryan:

When Nancy and I initially connected to talk about the project, I think one of the things that both she and I found a common ground was, is that we had done scar tissue work over the course of our careers. And part of the reason why Nancy started teaching, is she comes more from a lymphatic background. And she found that all the scar tissue workshops that were out there, were more directed towards after the fact. How to deal with problematic scars that had already formed. And both Nancy and I in our practice, were coming from the perspective of, is there something that we could be doing in the early stages of wound healing, that potentially could facilitate a better outcome? 

So that's, I really think is one of the key elements, with the book that we wrote, as we want to talk about the major systems involved in wound healing, deep dive into wound healing research, deep dive into inflammation, and how we can work with our hands in those very early stages, because there's a lot of misinformation out there about, you shouldn't be touching the patient for X amount of weeks. Both Nancy and I started working with patients within days, after some kind of injury or surgery. Of course, we're using our hands in ways that are different than perhaps we would use our hands if someone comes to see me and they've got a scar that's 10 years old.

Til Luchau:

That's great. I mean, I hate to keep putting myself in there. But that was actually my interest in developing that inflammation approach, because conventionally, a lot of hands are manual therapist, massage therapist. We're just told, "If it's inflamed, don't work it or let the inflammation come down." And there's something to that, but I really wanted to piece together for myself, protocols or principles that would allow me to safely work with people right from the beginning. So that's fascinating. That was your interest. Hey, by the way, one other divergence, are you going to the next fascial research congress in Montreal? 

Cathy Ryan:

Oh, absolutely.

Til Luchau:

It's September. 

Cathy Ryan:

It is. 2022.

Til Luchau:

Yeah, right. Oh, is it? 

Cathy Ryan:

Yes.

Til Luchau:

Yeah, you're absolutely right. So that's a year from now. Okay. So then I can ask you now, because they just let me know, it's still preliminary, but they just let me know that I'll be likely presenting a workshop, a one day inflammation workshop right before that congress in Montreal. And I would love it, if you would come heckle me. Or if I could even tempt you up on the stage, or at least wave height of people on there. 

Cathy Ryan:

It wouldn't take much convincing.

Til Luchau:

All right. 

Cathy Ryan:

You got it. I mean, Nancy-

Whitney Lowe:

You heard it here first folks, she committed. 

Cathy Ryan:

Nancy and I are tentatively on the list to potentially present a half day. So as long as it doesn't conflict, if we are not presenting, I'll make sure they don't-

Til Luchau:

If we're at the same time?

Cathy Ryan:

Yeah, make sure we're not at the same time, because I would love that, to be out there.

Til Luchau:

No, if we are at the same time, I'm going to sneak out of my workshop and come heckle you. 

Cathy Ryan:

I was going to do the same.

Til Luchau:

All right, great. That's cool that you're going to be there. So anyway, I'm sorry, you were just-

Whitney Lowe:

I wanted to backtrack to a moment to something you said about, this idea that massage therapists so much in their initial training, that both you and Till were saying this, we're taught to stay away from things, just stay away from wounds, stay away from scars. Can you elaborate a little bit, what is the primary cautions that we still do want to have and what are some of the misinformation that you've really learned now that may not have been accurate that was conveyed to us about why we should stay away from things? 

Cathy Ryan:

I think in the conversations that I've had with physicians, surgeons, I think there's concern about infection. Number one, as a massage therapists, we need to be mindful of open wounds and whatnot. The other thing would be interrupting the healing scar. So I think their concept sometimes of manual therapy is fairly assertive use of the hands that might somehow interrupt or reopen the scar as it's healing. I know certainly as a massage therapist, a contraindication for us would be that if someone comes in and they're still and they're bandaging over them, I would not be removing their bandaging to work around the area because of the risk of infection.

So in the conversations that I've had with surgeons, and this was one that I had not that long ago, a client who had been seen for quite a while, had to have some TMJ second subsequent surgery, because of one that had been an issue from years ago, and was seeing a different surgeon this time around. And after the surgery, the surgeon said to this person, "Don't let anybody touch it, no physical therapy, physiotherapy, no massage therapy, nothing for six weeks."

And she said, "Well, the massage therapists that I see, this is one of her areas. She's considered advanced in scar tissue work as a massage therapist, can I go see her?" And the surgeon was like, "Oh, no. I really don't want anybody touching it, because I don't want the healing process interfered with. I don't want any aggressive work on the tissue, because that could potentially up the ante in terms of hyper collagen proliferation." And she said, "Would you have a conversation with my massage therapist?" And he was like, "Sure." 

So I did have a conversation with the surgeon, and at the beginning of the conversation, my question was, "What are you concerned about?" So before I even launched into, "This is what I do, and blah, blah, blah." My first question for the surgeon was, "What are your concerns and why do you feel it's not appropriate for your patients to have any kind of manual therapy for six weeks." So the surgeon explained their concerns, which were the ones that I had mentioned previously about the hyper collagen proliferation. 

So then I described in the early stages, really what I'm looking to do, is help calm or sedate the nervous system, and just work with the edema to keep that to a minimum, because I understand from the wound healing research that, superfluous swelling can potentially be one of the drivers of hypertrophic scarring. So we engaged in this really great conversation, and at the end of the conversation, the surgeon said, "You may touch this patient."

Til Luchau:

That's a big thing.

Cathy Ryan:

That's a big thing.

Til Luchau:

The surgeon letting you in their territory. Yeah, that's a big thing. 

Cathy Ryan:

It is a big thing. 

Til Luchau:

So tell us what a hypertrophic scar is for those who may not know. 

Cathy Ryan:

Well, the hypertrophic scars are an overproduction of collagen. So you see within the scar margin, this lumpy, bumpy thickened tissue where essentially, the body has overdone it. More material than what is really necessary to close the wound and support restoration of function.

Til Luchau:

That's great. What else do you think you said that reassured him?

Cathy Ryan:

From my perspective, probably the thing that was most reassuring is that, I was able to convey that my knowledge around wound healing research was current. So I was able to talk to him about some of the research that supported my work or formed the way that I work with my hands, I was able to give the names of a couple of researchers whose work I was following and he was a kind of who is who of wound healing. So he recognized those names. So I think that I think probably was one of the things that was most reassuring, and just conveying to him what my intentions were in the early stages, not to interfere with the wound healing process, not necessarily to stop inflammation, but to manage anything superfluous.

Til Luchau:

And you mentioned, calming the nervous system, and helping modulate perfusion or edema, helping things not build up so much. So those were your early goals with a scar, is that fair to say? 

Cathy Ryan:

Yeah. 

Til Luchau:

Great. So what idea you said that people can have is that they shouldn't work on a scar too soon, and you're describing some ways or some goals that might open up some possibilities there. What other beliefs or ideas or assumptions might practitioners or clients have about scars that we would like to gently question? 

Cathy Ryan:

Exactly as the article for the title suggests. This stuff is not breakable. We cannot break down scar tissue. And I'll often say anytime I present or I am providing a course, I'll say to people, "If you take one thing away from this, just stop saying, break up down scar tissue, please just stop doing that." And my issue with the imprecision of that language is that, we will often try to model what the words imply. So if I have it in my head that I have to break this stuff up, I'm going to go in pretty hard and heavy to try to break this stuff up, when collagen has a tensile strength of steel. 

So we're not going to be breaking this time any soon. And anyone who's done any kind of cadaver work or cadaver courses, if you've seen what the stuff looks like inside the body, when you've got something that essentially looks like my Achilles tendon, after 30 years of massage therapy, my hands are pretty strong, but they're not that strong. And nor would I want to try to go at the patient in that way, because it's not a very patient-centered approach, in my opinion. 

Til Luchau:

You're describing the point of view that says one, if we think about breaking up scar tissue or breaking up adhesions, that's a fairly aggressive model to come from, and might not be aligned with those goals you had about calming the nervous system, for example. And then you're also questioning the possibility or plausibility that we would actually break a collagen connection in the body. 

Cathy Ryan:

Well, or be so aggressive with the tissue, that the body is going to escalate collagen production because we know that in recovery after injury, whether it would be a tendon, or whatever the case may be, our body will start to form material in response to the demands that are placed upon it. So we know that with the tendon recovery, there needs to be a certain amount of loading, so that the body has the message that it needs to in order to form tissue in a way that it's going to be able to do its job. So if we're- 

Til Luchau:

Sorry, say something about what you mean by loading, because, physios, people in that world know exactly what you mean. But in our field, manual therapy, that might mean different things. What kind of loading would help a tendon to recover? 

Cathy Ryan:

Well, loading would be like stretching or contracting the muscles that have a relationship with that tissue and/or the fascia. So we need to use our bodies in ways that we intend to go forward, and the ability to use our body.

Whitney Lowe:

I'm curious too about this sort of changing idea of what we're doing to those tissues. I know when I was originally training, Cathy, I think you and I went to school around the same time, in the late '80s. We were taught a lot of the woo stuff based on Cyriax's approach with deep friction for muscle strains and scars. It was torn tissue types of injuries, ligament sprains, and things like that.

And it did seem to be a treatment that got some beneficial results, that seems now that the theoretical model behind that, that we are helping to realign scar tissue or break up adhesions between adjacent tissues may not have been so accurate. So what's your take on like, where does that fit in that model? Is that now, it totally debunked? Or is that, where are we now with that idea and why does that help? Or seem to help in some instances of getting greater movement or freedom of movement after doing that type of treatment?

Cathy Ryan:

I don't know that we have the research to be able to really answer that question. But I have some theories on that. 

Til Luchau:

Oh, I can tell you, I can tell you. If I just go, I can do some quick research. If I open up my browser and type in like, can I break up adhesions? I'll get all kinds of evidence right there.

Whitney Lowe:

Oh, yeah. Great evidence. 

Til Luchau:

There's lots of people saying it one way or the other. In other words, it's either all about that, or it can't be done at all, and it's not about that, it's the debate. But you were saying, I'm sorry. 

Cathy Ryan:

I think it's reasonable that we can if tissues rather superficial, and I engage that tissue with fairly strong force with my knuckle let's say, and I grind back and forth across it, I can perturb that tissue in a way that the body will instigate some kind of response to that tissue being perturbed. So whether that instigates the release of collagen ease, and then that goes through a process of degrading the tissue, and then the body deforms new collagen, and because we're doing better things for ourselves, let's say during that reformation or remodeling stage, we end up with a better product. 

So I think there's the possibility that provocation techniques can potentially be useful in some circumstances, but I think it's been, when we think about Cyriax, it was intended to be done on very discrete areas of tissue fairly close to the surface. I don't really know that I could drive my elbow into someone's abdomen to try to get admin adhesion like this larger mass of tissue to get the same kind of productive results. 

I think based upon Stecco's more recent work, we do know that sharing types of techniques, potentially seem to have some kind of impact on getting the attention of fascia sites that release hyaluronan and/or they're responsible. So that sharing kind of motion, which is I use a fair amount in my practice, kind of a lifting and sharing type of technique. So very different than the provocation intended to facilitate a juicier more soft, pliable tissue, that allows for greater ease of moving.

Til Luchau:

Okay, so you were interested in fibrosis, but you're talking about juiciness?

Cathy Ryan:

Well, yeah, and I think fibrosis part of it may be a lack of juiciness, because not only is it the physical change in the tissue, but and this more into Stecco's work with densification, where we have a change in the fluid environment, within and around the fibers, which also could be part of why those fibers are less bendy and less pliable. So if we can, the way that I often talk about it when I'm teaching, its like reconstituting the sun dried tomato, that's conceptually what I think of when I'm using my hands, is you get this material that feels very dense and essentially dried out. And then you work with it for a while, and then it feels more like a sun dried tomato, where it's soft and slidy. And I can bend it and twist it. 

Til Luchau:

Nice. So that's very different than the sweater model of calming out the fibers say or calming them out and stretching them aligning them like, it came out of the Cyriax approach. I thought we were realigning fibers. I mean, back in my Rolf training, some people were whispering, "Hey, if you work on a sprain right away, you can actually realign the fibers while it's still in that pre inflammatory state." So we were in there combing out these fresh sprains and stuff thinking, that's what's going on. I mean and now looking back, I think there were probably, certainly things we were doing that were hopefully helpful. But I don't know that we were calming fibers as much as having some interesting fluid and contextual interactions with a person to help shift their experience. 

Cathy Ryan:

Yeah, and what I see with the people in my practice, I think the concept that I have is that, if I can render that tissue more soft and pliable, and they can move without pain, they're going to start moving more and the move by virtue of movement itself, we get a better alignment of fibers, and tissue that's going to function more normally.

Whitney Lowe:

I'm curious too, with this idea that where the manual therapy intervention is increasing that sort of fluid matrix environment around these tissues to try to enhance its mobility. How long does that last after the intervention is removed?

Cathy Ryan:

That's a great question, and of course, I have no specific answer for that. But I think what I've seen and I've heard back feedback from patients in my practice is, often I'll convey to them, "Okay, now that that is moving, your job is to keep it moving." So I don't know how long the specifics of the changes that my hands potentially facilitate will last, but if they can now move, their movement alone will help to facilitate that forward. So based upon the outcome that I've seen in practice. I've had patients come in with something not moving, and there's been some kind of shift or positive change with that. And then that change is sustainable going forward in a lot of instances, by virtue of now what they're doing for themselves, not so much what my hands potentially could facilitate. 

Whitney Lowe:

So it's almost like a kickstarting process of getting movement going? 

Til Luchau:

Or opening up a possibility, and then the future depends on how it's used and how it's utilized. But it's what we can do is open up possibilities. That's a question. I like it that you asked that Whitney because that's a question I get a lot ever since the beginning, even when I was thinking about fibers, people in the class or clients even would say, "Okay, so this is great, really quick results, but is it going to last?" And we had answers back then, we have answers now, and I say a lot of what you just said Cathy. 

But it's the real answer, I think that sometimes I'm brave enough to say is that, nothing lasts. Really, we don't know any manual intervention or movement intervention or life intervention that's permanent. It's all in various states of impermanence. And the best we can do is increase possibilities, options, likelihoods that things will keep being happy and keep moving, that kind of thing. 

Cathy Ryan:

Yeah, and all those things that we can do to help support better quality of life for folks. 

Til Luchau:

Okay, we talked about recent scars, we've tried to imply a little bit about older scars, what are some of the evidence based or evidence backed ways you think we can influence older scars?

Cathy Ryan:

Well, similar to what I was just talking about, in terms of, if you've got tissue that is under a lot of pressure, and the sponge is not able to reconstitute itself, that is really the approach that I take with older scars. And certainly, context is everything. So if someone's had massive amount of injury and multiple surgeries, the potential outcome for that individual might look very different than say, more simple surgery of some sort or injury. But in terms of working with patients, and again, we're talking about the things that were important to Nancy and I in writing the book, the other thing that was really important to us, is to always be mindful. And I take this quote from my dear friend, Pam Fitch, "That we're not just working with scars, we're working with people with scars."

And to approach from a whole person patient-centered kind of focus. So if someone, I'll give you one of the stories that Nancy likes to talk about in class, when we co-teach together. She had worked a number of years ago with an individual who was a nurse, and they had sustained, fairly significant burn injury when they were a child, so kind of the upper part of their body had been scalded, quite bad. And this individual, when they would go to reach for a pen, they couldn't get their arm very far away from the body and then had to kind of control to reach over to the desk to pick their pen up. 

And when Nancy asked this individual, what their goals were, they were just like, "I'll just like to be able to straighten my elbow out a little bit more, so I didn't have to control it so much when I went to pick up a pen." And Nancy was very successful in helping this individual achieve that particular goal. That's all they wanted. That was one goal. So it wasn't like, "I want you to make all my burn scars look homogenous-"

Til Luchau:

Invisible. 

Cathy Ryan:

"Which messes my body." Yeah, exactly. So I think that's a really important thing to be mindful of in terms of when working with older scars, one of the first questions I always ask any patient is, what are your goals? What would you like to see as an outcome, as a result of [crosstalk 00:28:25].

Til Luchau:

What would you say to a client that says, "Yeah, I want you to erase my scar?"

Cathy Ryan:

I would say, "Well, I'm not able to do that."

Whitney Lowe:

Right, and you can't photoshop it out of there? 

Cathy Ryan:

No.

Til Luchau:

But we'll see no testimonials, or advertisements or pictures of before and after scars. And I mean, you have some in your book that are pretty cool too or pretty dramatic. What's that about? I mean, when did they look different? What's good about that? Any downsides to think in that way?

Cathy Ryan:

Because they're changeable, right? And that's one of the other things with fibrotic tissue. It's not dead tissue, it's not necrotic tissue, it's fibrotic tissue. So our body's in constant flux. Anyone who's ever had any kind of scar, one of the first things they'll say to you is, "My scar, one year out looks very different than my scar 20 years out." Just by virtue of natural process, our scars will change over time, because our collagen is always in a state of flux. It's always in a state of turnover. So one of my questions is, if this collagen is always in a state of turnover, but let's say that tissue is under a lot of compressive force, or let's say it's hypovascularized, it's not getting the nutrition that it needs. If we can improve that situation over time, will the body render that scar, more cosmetically pleasing, let's say and more functional?

Til Luchau:

Okay, so you ask it as a question?

Cathy Ryan:

Yeah, and it would seem so. I did a presentation for the Polish Fascia Symposium, and I think you were there as well. 

Til Luchau:

Yes. There in quotes, right. 

Cathy Ryan:

Did you happen to see Alastair McLoughlin's presentation?

Til Luchau:

I did not. What did you get out of that? 

Cathy Ryan:

He's a scar tissue guy over in Europe, and he's been doing some research with the scar tissue work. And he showed a high definition real time ultrasound before and after scar tissue work. And what they saw around the scar, was it was there was very little vascularization. And then after the scar tissue work, you could actually see the blood going to the scar, which was really exciting. I surmise that that's likely, because we can see the change in the pigmentation of scars when we work with them, but it was really cool to see that, and wouldn't I'd  love to have a high definition time ultrasound unit.

Til Luchau:

Yeah, to look inside. 

Cathy Ryan:

Yeah. 

Til Luchau:

Yes, that's right. That would be cool. I sometimes think that, and then I reassure myself a little bit by going, "Oh, I actually do have a high definition, perceptive device here at the end of my two arms that can feel some amazing stuff in there. And that often correlates really well with what the client feels as long as I keep in mind that they're two different things, [inaudible 00:31:34]. 

Cathy Ryan:

Absolutely.

Whitney Lowe:

I'm curious too.

Cathy Ryan:

But it was cool to see though.

Whitney Lowe:

Yeah. I'm curious in terms of treatment approaches and treatment strategies, do you have a different technique approach that you would use for more superficial type scars, let's say, wounds, surgical scars, things that are in the skin, as opposed to deep scarring from, let's say, deep muscle strain or ligament sprain or something like that.

Cathy Ryan:

Definitely, and it really is accessibility, certainly requires us to use our hands in different ways. So stuff that's more superficial, or in certain areas of the body. I can actually get to hold the tissue and lift it, which I do a lot of in my practice. I describe it as ballooning or lifting the tissue, and then applying a bit of what I would describe as micro shearing in the areas where I feel that dense and dense fibrotic, kind of compressed feel of tissue.

When we're working in deeper areas like the abdomen, I can't really do that. So then I have to go more like a compression into the tissue to apply. But sharing for me, it's pretty much always a given. And not necessarily just with the scar tissue work that I do. With work in general, in my practice, I do a lot of sharing kinds of techniques. And it's interesting, because I've been doing that for quite some time. So at the last fascia congress, when Dr. Carla Stecco was talking about sharing, and the fascia sites seem to have an affinity for sharing, and [inaudible 00:33:21] and I was like, "Oh, yes, that's it. That's why."

It was a really exciting moment for me to have. And again, like you Til, I have my hands and I'm very reliant on what my hands feel and have been over the years. But it's cool to get that kind of information confirmation.

Til Luchau:

Yeah, that's right. And to have new narratives about what's happening, about what we feel because I was also excited by these Stecco's work early on, it's been great to see them, really develop it and articulate it and fill it out. It does give some alternative explanations for what we're feeling and what our clients are feeling. Who knows they're all explanations, but this is an interesting one, it's proving really useful. Whitney you had a question there about scars and adhesions and how they feel under the skin. 

Whitney Lowe:

Yeah, I was curious for your take on this Cathy, because I seem to hear manual therapist talking so frequently about, "I feel this adhesion or this scar, this thing under the skin here." And we can't actually see it, we can't actually know that that's really true. So I was curious about your take on that. How accurate do you think we can be about recognizing scarring and/or adhesion in the subcutaneous tissues for that mystery thing that we think we're feeling with our hands?

Cathy Ryan:

I think we can be really accurate with that. It'd be really interesting to do a study where they had a practitioner who's seasoned and well versed and feeling for this stuff, kind of palpate around to say, "I feel this and I feel like running in this direction." And then if there was some kind of high definition real time ultrasound or something that or an MRI or whatever, to come in and say, "Oh, yes, that exactly follows the line of what we're seeing on this imagery." I think those of us who have worked with our hands for a really long time, I think we're quite skillful in feeling that stuff, because it does feel different, we can feel areas of tissue that feel different.

And when we get engage that stuff that's dense, and sometimes you can feel the difference and the texture of it, in addition to the density or the compression of it. Oftentimes, we will get corresponding feedback from our client, from our patient that says, "When you engage that, I can feel that strong sensation of such and such, or I can feel that that's like when I try to move, there's something feel stuck there. It's like tethering me, I can't do that movement." So we often will get that reinforcement from our patients, saying, "That's it. Whenever you get your hands on there, that's it."

Til Luchau:

That's it. And for me, that's my definition of accurate. More than like, could I find it on an ultrasound? But can I get agreement with my client? There's a subjective milestone of accuracy, say than, if the ultrasound shows to me cool, but if my client feels it, even cooler, if it makes sense. 

Cathy Ryan:

Definitely. 

Til Luchau:

So that's the bridge that I'm been trying to weave for myself. And then, apparently what I do Cathy, is I invite guests to come talk so I can tell them my opinions, because that's what I'm doing. I'm saying that-

Cathy Ryan:

Excellent. 

Til Luchau:

What I'm trying to do is get the people in my classes to do that, to feel something and then see if their client can feel it and have a conversation about that, because that's the richest place to work. It's more work say, than just working on scar tissue and stopping there, I have to work on the person who has a scar or include them in the conversation. But that for me is where it gets really relevant and accurate.

Whitney Lowe:

And also having to get rid of those narratives that you said that we're promulgating about, we're breaking this up for you, you know? 

Til Luchau:

Yeah, right. 

Whitney Lowe:

Because that person says, "Oh, I feel much freer now, you must have broken up all those adhesions that I have in there that you told me about last time." So you have to find a way to not do that. 

Cathy Ryan:

Well, and it's been fascinating for me over the years, because really, it has been my clients who have educated me in a lot of ways, because in the early days of doing this work, they would say to me, "I know this is going to sound a little weird, but it feels like you're such and such," and they'll describe what they're feeling inside their body. And then as I progressed, and got to understand more of what perhaps we are doing, it's like what they described, was physiologically what was happening. It happened so many times in my practice that for me, I was just like, listening to what the patient is saying, what they're describing, because that's their body, they have that intimate relationship with their body that we will never have. So for me, what they have to say is number one.

Til Luchau:

And it's worth. I mean, I'm trying to keep in mind for myself too that the scar isn't just in the physical tissue or the little visible externally part, that an injury and something like that, it affects the way we feel from the inside out, inside the kinesthetic body or the felt body, and that that's often what I'm thinking about working as I go too. Is that in your model?

Cathy Ryan:

Absolutely. And for me, one of the things that I'm known for here in Canada as a massage therapy educator, is work within the interpersonal therapeutic relationship with patients. So that's a big part of my practice. It's been part of what I've taught here in Canada. My dear friend Pam Fitch, I consider her to be the queen of ethics, professionalism and therapeutic relationship. She's my go to, I've learned a tremendous amount from her. 

So dialoguing with the patient is such an important part of my practice and listening to what they have to say about what they're noticing or feeling in their body. I think it's just really paramount to being a good practitioner. Yes, we need some skill with our hands. But I think there are times where our demeanor, the way we converse with our patients, begins the therapeutic process before we even get close to them with our hands.

Whitney Lowe:

Yeah, so it's a lot more than just the pressure of doing something to those tissues, there's a whole big picture integration happening there for sure.

Cathy Ryan:

A huge picture. Now, it's another part of the book that was important for Nancy and I and why we called it Traumatic Scar Tissue Management and not just scar tissue management, because we also want to speak about the experience of the person might be having with their scars. We have some folks who their scar is like a badge of honor, and they're like, "Yeah, blah, blah, blah, and that's how I got the scar," and that goes across all genders, so not to make any kind of assumption there. And then there are other folks who are just the tiniest of scar that's barely visible, can just feel catastrophic to that individual. So again, it's being careful about our own narrative about scars, and really listening to how the patient feels about those scars. 

Oftentimes, I have people come into my practice, and they're three months out from a new knee or new hip. And part of what they want to know is, "Is this normal? Is this what you're seeing with other patients as far as where my scar is at and my range of motion is at three months out, am I doing okay here?" So I can help conveyed based upon my years of practice of working with new knees and new hips. You're in that kind of target range of, that looks pretty good to me and that feels pretty good to me. So sometimes my practice is more about people just needing another voice to say, "Hey, you know what, that looks pretty good. You're healing really well."

Whitney Lowe:

Mm-hmm (affirmative), yeah.

Til Luchau:

Okay, so a little bit of a random question here. It kind of relates to what we were saying. But what do you think about the fuzz question?

Cathy Ryan:

The fuzz? 

Til Luchau:

The fuzz question, Gil Hedley's fuzz speech-

Cathy Ryan:

I love it. 

Til Luchau:

Which inspired so many people and inflamed so many people to say, hey, it's not quite like that. Where are you in that?

Cathy Ryan:

Oh, I was one of those people.

Til Luchau:

[inaudible 00:42:14], he says when we go to sleep, for example, we wake up and there's a bunch of fuzz in between our muscles and he shows us in the dissection this cotton candy stuff and says you got to move, keep this cotton candy from building up. 

Cathy Ryan:

I was all over the spot fuzz thing until I went to the First Fascia Congress, and Dr. Guimberteau showed his stuff. And then further on from that, that when we extract all the fluid out of the body, all those fine bits of loose connective tissue that forms our sliding mechanism, you take all the water out, and that just all collapses on itself and looks like a bunch of bugs. And I think even Gil, I think that the next Congress, he did the fuzz speech, revisited and had to change it.

Til Luchau:

That's right. No, we've had him on the-

Cathy Ryan:

I don't know if that was quite accurate. 

Til Luchau:

Yeah, we had on the podcast, and that's basically what he talked about as well. He was like, "That was a cool thought, but now I had to refined it a little bit and there's still something to it," he said, but you're describing Guimberteau's high resolution pictures of picking up the skin and looking under it and all of the fluid connections and structures, did that made visible? That's what I was thinking about when you're talking about your lifting work in your hands on approach too. It's like you're doing your own little Guimberteau tour right under the skin there. 

Cathy Ryan:

Yeah, I mean for me, I went to that initial Fascia Congress in 2007. I went there to cover it for Massage Therapy Canada Magazine. And so I was there doing reconnaissance for the magazine and because of my own keen interest in fascia too. And Guimberteau's work, was one of those moments that has changed my hands for forever, because that was the moment that I started thinking more about the fluid environment. Not that I tossed out the fibers, but I really started thinking about the fluid environment and potentially what our hands might facilitate in terms of what I'm feeling and what the patient experiences. So that for me was like an extraordinary moment of aha and I was definitely one of those people who was yelling, and fist pumping in the air when he was doing his presentation, like so many of us were. I think we scared him. 

Til Luchau:

Right, Now that parallels my own shift in thinking and also what I got out of going to those congresses, again, there's this more detailed understanding of the fluid nature of our bodies and the tissues and just how much is going on. I mean, like Neil Theise's interstitium talk and ideas and Melody Swartz's the lymphatic and the deeper movements of cells within that. It's very exciting. 

Cathy Ryan:

It was exciting. 

Til Luchau:

I can't wait to see what's coming next.

Cathy Ryan:

Yes. And I mean, I had been following Robert Schleip's work prior to that. I'm a registered massage therapist, but one who has been influenced by structural integration in rolfing, one of my instructors back in the '80s, had just completed his training at the Guild. So he started to introduce us to this magical tissue called fascia that you can't find anywhere find any information about it. And at the time, that world was still pretty insular and not sharing information with other disciplines. So I got a little bit from my instructor and tried to find stuff, I couldn't find anything. 

And then, I think it was in around 2000 or somewhere, the early 2000s, that I discovered Robert Schleip's website Medics.de, and he was one of the first ones who was sharing information. So I started reading anything and everything that he was putting out there. And really, I would say, he's probably the reason why I was really wanting to go to that first fascia Congress, because of course I knew he would be there because he was one of the organizers. So it's kind of Robert Schleip was the impetus for me to really want to go there. And then of course, my world just exploded from there. And I'm really excited about the next one in 2022 in Montreal.

Til Luchau:

Yeah. 

Cathy Ryan:

It should be fascinating.

Til Luchau:

It's true for a lot of us. We're probably moving toward a summary a wrap up, but I got one more I want to just get your head on. You introduced me to Geoffrey Bove. I'd seen him present at the previous fascia congresses, but then I went and did a deeper dive with him about inflammation in his work around tissue qualities and nerve reactions, things like that. His study with, I'm blanking on her name now about the rats in the viscera.

Cathy Ryan:

Susan Chappele. 

Til Luchau:

Thank you, Susan Chappele. Are you familiar enough with that, to give us a little synopsis and your thoughts on that?

Cathy Ryan:

Susan is our MT colleague of mine here in BC, and they were looking at post operative adhesions, and potentially-

Til Luchau:

In the abdomen. 

Cathy Ryan:

Yeah, in the abdomen, in an animal study or rat study. And Susan was sort of massage therapy hands on for that study, and just looking at, they were part of demystifying that whole breaking it concept. But just looking at if we start moving the tissue round in the early stages, can we potentially prevent adhesions from happening in the first place? So that's kind of what their study was about. And I don't know if you've ever seen any of the videotape of Susan working post operatively, but she's not delicate. She's definitely a little bit more effervescent with the tissue than I often am. And there was no opening up the wound and that kind of stuff that is I think, is one of those misconceptions that's out there. 

Til Luchau:

If I remember right too, they were also for tracking for signs, withdrawal protection from the rats, the other one that do work within the range that the rats were actually responding to and seeming to enjoy.

Cathy Ryan:

Yeah, and then-

Til Luchau:

Because I remember that they would and I said I may not remember accurately, I should have gone back and read it, but they would they abraded the rats, viscera slightly with sandpaper, let it heal. During the healing process like you said, would do this visceral manipulation. You said not that gentle, but my impression, I get the opposite impression from the video it was pretty gentle. It was just by comparison to what I do. But then we had a panel go look at the tissues later and rate them [inaudible 00:49:19] for adhesions, and the ones that got manipulation had lower ratings of mechanical adhesions there. 

Cathy Ryan:

Yes. Yeah.

Til Luchau:

So that's been debated and criticize that study, because it was a study that people in science said, "Well look, look at this, there are adhesions and we can change them with manipulation."

Cathy Ryan:

Yeah. And then Jeff went on to do some of the great work with Mary Barbe on the whole, over use tendinopathy thing with some really great results on that as well. 

Til Luchau:

Key takeaways occurred to you on that one?

Cathy Ryan:

Basically, they had two groups of rats. Mary has this fantastic process of teaching the rats to pull lever to essentially give themself an overuse, repetitive strain, kind of-

Til Luchau:

It's coming back to me now. It is coming to us again. 

Whitney Lowe:

Yes. 

Til Luchau:

Yes, right. 

Cathy Ryan:

And they had one group of rats that were provided some manual therapy, and then another group that they were not. And in the manual therapy recipient group, they showed less abnormal collagen production, and also important nervous system changes as well. 

Til Luchau:

Lower inflammatory cell and within the nerves, so it was like less nerve inflammation. 

Cathy Ryan:

That's right, less nerve inflammation. 

Til Luchau:

I'm just like rolling it around and stretching them a little bit. 

Cathy Ryan:

Yeah, and less pain behaviors. So a number of different positive outcomes as a result of that, showing that in manual therapy for those individuals, let's say in a work setting that requires them to do a repetitive motion, if they were receiving care on a regular basis. This was a good potential that they wouldn't develop some of those overuse kinds of issues.

Whitney Lowe:

So it seems a lot of these things are less oriented toward what we have traditionally been told, and thought about scar tissue that were mechanically changing it and a lot more to do with, we're impacting the physiological environment around these things. And there's all kinds of neurologically and other physiologically mediated changes that occur as a result of that with our interventions. It sounds like that's the approach that we're looking at now. 

Cathy Ryan:

Well, and I think too the potential there to decrease pain translation as well, because of these different neurological changes that we're seeing. So less of a potential for people to transition from an acute pain type of presentation to something that's more of a complex pain, type of scenario.

Til Luchau:

So managing the sensitization process. 

Cathy Ryan:

Yes. 

Whitney Lowe:

Yeah, mm-hmm (affirmative). 

Til Luchau:

All right. So early on, in the scarring, you said, you were thinking about calming the nervous system, helping with fluids, later on in the scarring process, you said you continue to think about fluid perfusion. Anything else you want to throw in there for a summary of your key points?

Cathy Ryan:

I think the key point-

Til Luchau:

In terms of the application, like how do we use this information?

Cathy Ryan:

Yeah, I mean, I think really for me, the way that I use my hands in terms of post surgically later on, let's say, and how I might work with someone with an overuse injury or a sprain or a strain, I use my hands in the same way. So Nancy and I have stayed away from some kind of proprietary sort of moniker for the names of the techniques that we use, because really, some of the stuff that we all learn, maybe we just helped to refine the way that when and the way that we're using our hands. 

Til Luchau:

Nice. And it just brings to mind your conversation on the ABPMP Podcast with Darren and Kristen, where the title they came up with was, was it slow down and lighten up? 

Cathy Ryan:

Slow down and lighten up?

Til Luchau:

That is the takeaway from this, so it's great. Anything else Whitney before I do our close-up?

Whitney Lowe:

No, I think it's been a fascinating deep dive into this. And I just certainly want to say I really enjoyed your book and have learned a lot of stuff and I've gotten a lot of new lightbulbs for things that I want to explore in greater depth as well. So I really thank you all for putting forth the effort to look into this topic and share what you've learned with the rest of the community here. 

Cathy Ryan:

Well, thank you so much. And I mean, I know who both of you are and have been following your work for a really long time. So it's just such a treat to be here and to be able to learn from both of you and have engaged in the conversation, really rich conversation. 

Til Luchau:

Nice.

Cathy Ryan:

Thank you.

Til Luchau:

Thank you Cathy. So if people want to know more about you and your work, we'll put some links to say the book and the article in our show notes. But what else? Where else would you direct people? 

Cathy Ryan:

My email address, so if you want to post that I'm always happy to receive questions from folks. And I'm just going to quickly mention another place that you can find as a chapter contributor, is to another new fantastic Handspring book called Oncology Massage: An integrated approach to cancer care by Janet Penny and Rebecca Sturgeon of Healwell. So I've got some stuff in there and Nancy does as well. So I get into a little bit of talking about radiation induced fibrosis. So if anyone's interested in working with oncology patients, really fabulous new resource available.

Til Luchau:

Great, thank you for that. We'll put all that in the show notes. So, do stop by and have a look at those. I want to thank our closing sponsor, which is the Healwell Community. They are an interdisciplinary online community, founded by massage therapists for serious health care professionals who know how to be real, curious, professional, kind, silly, and collaborative. They say, in the Healwell Community, you'll have the chance to engage in honest conversations with practitioners from a variety of disciplines who talk about the issues that keep us from offering the best care.

Whitney Lowe:

Healwell Community members connect with colleagues from a variety of healthcare disciplines for discussion and education about monthly themes, like the BIPOC provider experience, weight bias and health care and LGBTQIA issues in healthcare and more. Community members also get a 10% discount in all Healwell's continuing education courses, so be sure to check that out today at community.healwell.org and we want to say thank you to all of our sponsors, also to the listeners, thanks so much for hanging out with us and I hope you've learned some stuff. You can stop by our sites for show notes, transcripts and extras. You can find that with my site at AcademyofClinicalMassage.com and Til where can people find that from you?

Til Luchau:

My site where all those things are is advanced-trainings.com. If there are questions, or things you want to hear us talk about, you can email us both at info@TheThinkingPractitioner.com or look for us each on social media, just under my name, Til Luchau. How about you Whitney? 

Whitney Lowe:

You can find that under my name on social media as well. You can also follow us on Spotify, Google podcast. Rate us on Apple podcast if you can. That really helps people find the show and wherever else you happen to listen, and please, do tell a friend. And of course if you're unable to find us in any of those locations, you can grab a Collector's Edition DVD of outtakes from Gilligan's Island and put it upside down in your Sony disc command CD player and you can hear us there, and that's all we got.

Til Luchau:

Thanks Whitney, thanks Cathy. 

Whitney Lowe:

All right.